Most infants presenting with wheeze in the first year of life have bronchiolitis. Most cases of bronchiolitis occur
between 2 and 5 months of age, in airways with very small calibre.
Bronchiolitis is usually caused by Respiratory Syncytial Virus, but can also be caused by rhinovirus, adenovirus, influenza
and parainfluenza viruses. It starts with 2-3 days of coryzal symptoms and progresses to cough and wheeze with fever and
Wheezes and crackles are usually heard throughout the chest. Focal chest signs suggest alternative diagnoses such as
pneumonia or aspiration.
Infants with bronchiolitis often get worse for the first 72 hours of their illness and then start to improve. Symptoms
may take several weeks to resolve, with a median duration of approximately 12 days. Children and parents need support
during this time.
Bronchiolitis has a 1-2% mortality rate and infants with hypoxaemia related to small airways obstruction may need treatment
with racemic epinephrine and steroids in addition to oxygen, intravenous fluids and nasogastric feeding.
Management of bronchiolitis is mostly supportive
Interventions such as bronchodilators, adrenaline, steroids and antibiotics have not been shown to be beneficial in
uncomplicated bronchiolitis. Management is supportive but may include the need for oxygen, nasogastric feeding or intravenous
fluids. Primary care clinicians need to know the features of moderate to severe bronchiolitis so that they can manage
it appropriately but also so that they can educate the parents of children with bronchiolitis about recognising deteriorating
Assessment of severity
Table 1: Assessment of severity of bronchiolitis
Get a PDF of tables 1,3,4,6 here
|Under 2 months >60/min
|2-12 months >50/min
|Chest wall indrawing
||Less than usual
Quantity >1/2 normal
Quantity <1/2 normal
|History of behaviour
Any criterion in the severe category designates the child as severely ill
Recognising severe illness in children
- Behaviour and feeding both go from interested infant, to infant not interested
- Respiratory rate
- A newborn may breathe up to
- 60 breaths/min
- A 1-year-old: 40 breaths/min
- A 5-year-old: 30 breaths/min
- If the rate is high, look for potential respiratory failure using 2 key signs
- effort, and
- effectiveness of effort
- Increased effort is indicated by sounds
- Stridor in upper airway obstruction
- Wheeze or grunting in lower airways obstruction
- Accessory muscle use producing nasal flare, heaving chest, intercostal and subcostal indrawing
- Effectiveness of effort is indicated by looking at the chest movement and listening to breath
sounds to judge ventilation:
are all preterminal events.
- A silent chest
- Falling heart rate
- Falling level of consciousness
- Falling respiratory rate in severe illness
- During respiratory failure, skin colour changes from pink to pale, to mottled.
Pale colour indicates vasoconstriction and mottled indicates terminal circulatory collapse.
Reference: Bone J. Recognising the very ill child NZ Doctor 14 Mar 2007.
When to refer with acute bronchiolitis
As a general rule refer infants earlier rather than later: if in doubt get specialist advice.
Refer all infants immediately with; severe illness (see Table 1), progressive dehydration,
where there is clinical concern about hypoxia or a history of apnoea.
- If less than 8-weeks-old or if birth was significantly premature (<32 weeks gestation)
- If there has been apnoea or significant comorbidity (heart and lung disorders, immune-compromise)
- If illness is getting worse after 72 hours or home care is uncertain
Management of bronchiolitis at home
Most infants with bronchiolitis can be safely managed at home. Supportive care plus careful observation for signs
of deterioration are the keys.
Supportive care may include:
- Keeping the child’s environment smokefree
- Keeping the child well hydrated
- Small frequent feeds
- Minimal handling
- Normal saline nasal drops before feeds
- Caregiver hand washing to prevent spread to other children
Written instructions will help caregivers to keep an eye on feeding patterns and behaviour and to monitor
- Respiratory rate
- Nasal flare
Infants with a moderate episode of bronchiolitis need to be reviewed within 24 hours and a firm appointment (time,
place, person) helps to ensure the child is seen. (For an example of written instructions for caregivers see
Cough in children
Cough in children has different causes to cough in adults and symptomatic treatment is rarely needed or effective.1 The
smaller airways are vulnerable to inflammatory disease causing swelling and obstruction by mucous secretions. Coughing
assists clearance of mucous, so do not attempt cough suppression.
It is reasonable to categorise childhood cough as:
- Acute cough - lasting less than two weeks
- Persistent cough - lasting two to four weeks
- Chronic cough - lasting over four weeks
Acute cough is usually viral
Most acute cough in children is associated with viral upper respiratory tract infections (URTI). The majority
of these (70-80%) will resolve within one week although 5% will persist for more than four weeks.
No over-the-counter or prescription medicines are effective for the symptomatic relief of acute cough in children but
there does appear to be a significant placebo effect. Over-the-counter cough and cold medicines are a significant cause
of morbidity, especially from accidental overdose.
It follows that we should look for something soothing and safe for children with acute cough. Honey and lemon drinks
have stood the test of time and can be made at home at little cost. However, water should not be boiled, firstly because
children are not usually used to hot drinks and secondly because there is risk of scalding.
Aspiration may be missed
Characteristics of an acute cough may raise suspicion of specific causes such as the barking cough of croup or
the paroxysmal cough of pertussis. When there are no symptoms of a viral infection, careful consideration needs to be
given to an aspiration episode, particularly in younger children. Aspiration most often occurs when an older sibling has
fed a young child unsuitable food.
Cough soon after birth is cause for concern
Cough that begins at, or within a few weeks of birth always raises concern. Congenital causes include tracheomalacia,
tracheo-oesophageal fistula or laryngeal cleft. Cough starting within a few weeks of birth raises the additional possibilities
of suppurative lung disease, aspiration, gastro-oesophageal reflux or infection with chlamydia trachomatis. Cough in a
neonate often warrants discussion with a paediatrician.
Cough continuing beyond four weeks needs careful evaluation Although a non-specific post-viral cough is still the most
likely diagnosis, children who continue to cough beyond four weeks need evaluation to exclude more specific causes. Evaluation
of a significant ongoing cough includes history and physical examination with consideration of the need for chest x-ray
and, if the child is old enough, spirometry.
Passive or active smoking is a common cause of cough in children. Fifty percent of children over the age of two years,
with at least two family members who smoke, have cough.
Some specific causes suggested by the history and examination are described in Table 2:
Table 2: Specific causes of chronic cough suggested by the history and examination
||Specific cause of cough
||Asthma or aspiration
||Tracheomalacia, foreign body
|Moist cough, clubbing or Failure to Thrive
||Suppurative lung disease, cyanotic heart disease, cystic fibrosis, immune or ciliary disorders
|Aspiration episodes or swallowing difficulties
||Foreign body or aspiration
|Paroxysmal cough or family members with persistent cough
|Honking cough absent during sleep
||Psychogenic or habit cough
|Staccato cough with or without conjunctivitis
Cough from post-nasal drip, gastro-oesophageal reflux and ‘cough variant asthma’ are unusual in children
Studies show that post-nasal drip is unlikely to cause cough in children and the cough is more likely to be related
to coexistent lower airway pathology. The use of medications to ‘dry up’ nasal secretions is therefore unlikely to help
Gastro-oesophageal reflux has been suggested as a common cause of cough in adults but there is no convincing evidence
that it is a common cause of cough in children.
Some children with isolated persistent cough without wheeze receive a diagnosis of ‘cough variant asthma’. However there
is no evidence that this is really a form of asthma. Few children with isolated chronic cough have eosinophilic inflammation,
atopy or airway hyperresponsiveness and they do not respond to bronchodilators or corticosteroids.
Cough may be the predominant feature of asthma but is usually accompanied by wheeze. Isolated chronic cough with no
apparent underlying cause is more likely to be related to a hypersensitive cough reflex.
Treatment of chronic cough targets the cause not the symptoms
Symptomatic treatment of chronic cough is usually not effective or appropriate. It is the underlying cause, which
should be the target of therapy.
- Antihistamines are proven to have no benefit in chronic cough and are associated with high levels of side effects
- Cough suppressants such as dextromethorphan, pholcodine and codeine are contraindicated in children
- Menthol inhalations are not effective and are associated with risk of scalding injuries from boiling water
- There is no evidence for effectiveness of herbal remedies
- Emetics, such as guaifenesin, ammonium chloride, ipecacuanha and squill, are used in low doses as expectorants but
are not effective
Nevertheless, the significant placebo effect of cough medicines may convince parents that one is needed. A simple soothing
demulcent, with ingredients such as honey and lemon, syrup or glycerol, may help reduce coughing and irritation. It is
best to avoid those with high sugar content. Lozenges are associated with risk of choking for children, especially those
under the age of three years.
All children with cough will benefit from a smokefree environment.
Fever in children
Search for a cause,
manage the symptoms
Fever is an appropriate response to infection and has some beneficial effects. For example, fever can make the environment
less favourable for microorganisms to multiply and certain parts of the immune system work better at slightly higher temperatures.
However, sustained high temperature adds to insensible fluid loss and risk of progressive dehydration.
Febrile convulsions occur in 3-4% of children with fever. Although they are associated with fever, they are not prevented
by antipyretic medications such as paracetamol. Febrile convulsions, if they do occur, are usually brisk and not likely
to cause brain damage or learning disabilities. Complex febrile seizures can occur and may be prolonged. If prolonged
(>15 minutes) they should be treated with rectal diazepam.
Antipyretic medications along with physical interventions, such as cool drinks and reducing excessive layers of clothing,
can be appropriate to manage discomfort which may be associated with fever.
|Measuring the temperature of children under five years
||Electronic thermometer in axilla
||Chemical dot thermometer in axilla
||Infra-red tympanic thermometer
|X Oral thermometer
|X Rectal thermometer
|X Forehead crystal thermometer
Stratification of risk for serious pathology clarifies management decisions
Risk stratification for children with fever
Practitioners will always want to conduct a careful search for a focus of infection for any child with a fever and this
can be combined with assessing the risk of serious pathology. Urinalysis of a clean catch urine sample is an essential
part of this assessment when no obvious causes are apparent.
Get a PDF of tables
|Table 3: High risk of serious pathology
||Table 4: Intermediate risk for serious pathology
|High risk features
||Pale, mottled, ashen or blue
||Weak, high-pitched continuous cry
Diminished level of consciousness
Unable to rouse or if roused does not stay awake
RR >70 breaths/min
Moderate to severe chest indrawing
||Reduced skin turgor
Capillary refill time >3 secs
||Non blanching rash
Focal neurological signs
Bile stained vomiting
Swelling of limb or joint, non-weight bearing, not using an extremity
High temperatures need to be interpreted with regard to other signs and symptoms, however
T >390C should be regarded as a high risk feature
Any of the above features place a child in a high-risk category for serious pathology.
The child needs immediate admission to hospital.
|Intermediate risk features
||Not responding normally to social cues
Wakes only with prolonged stimulation
||Nasal flaring: age over 12 months
Age 0-2 months, RR >60 breaths/min
Age 2-12 months, RR >50 breaths/min
Age >12 months, RR >40 breaths/min
||Dry mucous membrane
Poor feeding in infants
Reduced urine output
||Fever for >5 days
In the absence of high-risk features, any of the above features places a child at intermediate risk of serious pathology.
Depending on the findings and circumstances, one or more of the following may be appropriate:
- Referral for urgent paediatric assessment
- Telephone consultation with a paediatric specialist
- Firm arrangements, time/place/person, made for a further review
- Written and verbal instructions on warning symptoms that may occur and how to respond to them
Table 6: Features of some of the serious causes of fever in children
|Diagnosis to be considered
||Signs in conjunction with fever
||Non blanching rash PLUS one of:
An ill looking child, petechiae or purpura, capillary refill time >3 secs, meningism
||Neck stiffness, bulging fontanelle, decreased level of consciousness, limpness
(NB Neck stiffness and bulging fontanelle are relatively insensitive signs of meningitis)
|Herpes simplex encephalitis
||Focal neurological signs, focal or generalised seizures, decreased level of consciousness
If wheeze is present the diagnosis of pneumonia is less likely
|Tachypnoea: Age 0-2 months, RR >60 breaths/min
Age 2-12 months, RR >50 breaths/min
Age >12 months, RR >40 breaths/min
Crepitations, nasal flaring under 12 months, chest indrawing, cyanosis
|Urinary tract infection
||Vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, dysuria or increased frequency, offensive
urine or haematuria
||Swelling of a limb or joint, not using an extremity, non-weight bearing
|Fever >5 days WITH at least four of the following:
Rash, conjunctivitis, lymphadenopathy, cracked lips, skin peeling
Be alert for signs of septicemia, i.e. significant fever (>380C)
PLUS lethargy (not interested, not feeding) and/or significant dehydration (dry mucous membranes,
poor urine output, capillary return >2 secs) and/or fast respiratory rate with increased effort and signs of poor effectiveness
If a child becomes rapidly ill or is particularly ill, with a rash, consider and exclude meningococcal disease.
The rash may present as a morbilliform or subtle petechial rash before progressing to a purpuric rash.
Acute gastroenteritis in children
Presentation of gastroenteritis may suggest cause
Viral infections cause most gastroenteritis in children in New Zealand. They usually produce low-grade fever and watery
diarrhoea, without blood.
Rotavirus, the most frequent viral pathogen, tends to be seasonal, with late winter peaks, and most frequently affects
children between 6 months and 2 years of age. Most children will come in contact with the virus and, as immunity is long
lasting, infection is uncommon in adults.
Norovirus affects all ages, as immunity does not last long. Infection tends to occur as outbreaks in institutions such
as preschools, childcare centres, hospitals and rest homes.
Bacterial infections are more likely to be associated with higher fevers and blood or mucus in the stool. They may also
be associated with abdominal pain or systemic effects, from spread of the bacterial pathogens themselves or associated
Viral infections are usually transmitted by the faecal-oral route or by respiratory droplets but they can linger on
contaminated surfaces. Bacterial infections are often acquired by the ingestion of contaminated food or drink which has
not been properly cooked, stored or processed. Chicken, beef, pork, seafood, ice cream and reheated rice are all frequent
sources of bacterial gastroenteritis.
Water may be contaminated with viruses, bacteria or protozoa.
Most Gastroenteritis in children is viral
There are many causes of acute gastroenteritis in children (Table 7)2 but the majority
are caused by rotavirus or norovirus.
Table 7: Causes of acute gastroenteritis in children
|Pathogens causing acute gastroenteritis in children
Viruses - approximately 70%
- Enteric adenoviruses
Bacteria - 10 to 20%
- Campylobacter jejuni
- Non-typhoid Salmonella spp.
- Enteropathogenic E. coli
- Shigella spp.
- Yersinia enterocolitica
- Shiga toxin producing E. coli
- Salmonella typhi and S. paratyphi
- Vibrio cholerae
Protozoa - less than 10%
- Giardia lamblia
- Entamoeba histolytica
- Strongyloides stercoralis
1. Is the child shocked?
Features of shock in a child may include:
- Drowsy or comatose
- Rapid, thready pulse
- Cold, blue peripheries
Skin retraction and capillary refill are less reliable signs.
Shock is an emergency and the child will need immediate hospitalisation. Consider the need for intravenous or intraosseous
access if there will be any delay in getting hospital care.
2. Is it really viral gastroenteritis?
The differential diagnosis of viral gastroenteritis is not always easy. Sometimes in the middle of an epidemic the diagnosis
can be mistakenly applied to a child who has another cause for their symptoms. It is worth remembering:
- Not all vomiting is gastroenteritis
- Not all diarrhoea is gastroenteritis
- Not all gastroenteritis is viral
Not all vomiting is gastroenteritis
Vomiting may precede diarrhoea in rotavirus, but isolated vomiting always raises suspicion of another cause. Bile stained
vomiting means bowel obstruction until proven otherwise.
Surgical conditions that may present with vomiting include:
- Pyloric stenosis (typical age about 6 weeks)
- Intussusception (typical age about 6-10 months)
- Intestinal obstruction
Other possible causes include:
- Infections such as urinary tract infection, otitis media, pneumonia
- Metabolic disease such as diabetic ketoacidosis and inborn errors of metabolism
- Head injury
Not all diarrhoea is gastroenteritis
Other causes for diarrhoea need to be considered. These include:
- Antibiotics or other medications
- Spurious diarrhoea secondary to constipation
- First time presentations of chronic diarrhoea, such as coeliac disease
Not all gastroenteritis is viral
Bacterial gastroenteritis has higher complication rates and worse outcomes than viral gastroenteritis. Factors that
may raise suspicion of bacterial gastroenteritis include:
- Blood or mucous in the stool
- Higher fevers
- Systemic toxicity
- Abdominal pain
- Association with outbreak linked to contaminated food source
Suspicion of bacterial gastroenteritis is an indication for stool culture. Campylobacter is the most common form of
bacterial gastroenteritis. Antibiotics are not indicated for campylobacter gastroenteritis unless the child is systemically
unwell, as they may prolong the diarrhoea or carriage of the organism.
If the child is systemically unwell, erythromycin may be considered.
3. Is the child dehydrated?
Documented recent weight loss is a good indication of the level of dehydration but these measures are often not available.
Unfortunately clinical estimates are not very accurate and the categories of dehydration, which can be defined by them,
are very broad.
Table 8: Signs of dehydration in a child
||Clinical signs of dehydration
||Skin fold retracts immediately
|| Two or more of:
- Restlessness or irritability
- Sunken eyes
- Deep acidotic breathing
| Slow retraction of skin fold
- visible for less than 2 seconds
|Severe dehydration with or without shock
|| Two or more of:
- Abnormally sleepy or lethargic
- Sunken eyes
- Drinking poorly
| Very slow retraction of skin fold
- visible for over 2 seconds
4. Can the child be managed safely at home?
Children over 6 months with viral gastroenteritis of less than 24 hours duration, low-grade fever, mild levels of dehydration,
no abdominal pain and minimal systemic symptoms can usually be managed safely at home. The decision is often a difficult
clinical judgement and will be strongly influenced by home circumstances and ability to provide regular medical follow
Oral rehydration is safe and effective for most children
Oral rehydration therapy for dehydration from gastroenteritis is safer and more effective than intravenous therapy for
all degrees of dehydration other than shock. However it requires a lot of input from the child’s caregiver.
Vomiting is not a contraindication to oral hydration. Most children with gastroenteritis who vomit, will still absorb
a significant percentage of any fluid given by mouth or nasogastric tube.
Fluid replacement occurs in two phases: rehydration and maintenance
Commercial oral fluid replacement solutions, such as Plasmalyte and Pedialyte, are mixtures of sodium and potassium
salts, a base (citrate or bicarbonate) and a carbohydrate. They are designed to correct deficits in water and electrolytes
caused by diarrhoea. If the child is lethargic and the skin feels dry and inelastic, dehydration is likely to be associated
with low sodium. If the child has hypernatraemic dehydration, thirst is extreme and the skin feels doughy.
Breast milk, formula, cow’s milk (if the child is over one year), clear soup or rice water are all suitable. Highly
diluted juice or lemonade can be used if there is not a better alternative, at a dilution rate of one part juice to five
parts water. Lemonade is diluted with warm water to get rid of the bubbles.
Cola, tea, coffee or sports drinks are not suitable because of their high stimulant
or sugar content
During the rehydration phase, fluid is given at a rate of 5 ml per minute by teaspoon or syringe. The small volumes
decrease the risk of vomiting. The rate (1 teaspoon/minute) is easy to calculate and administer for a parent sitting at
the bedside. This can be changed to 25 ml every 5 minutes once the child stops vomiting.
This rate will rehydrate a moderately dehydrated 1-year-old in 2 to 4 hours and a 2-year-old in 3 to 5 hours.
Frequent review (at least 2 hourly) is advisable in the rehydration phase. A child who is not rehydrating
at this rate of oral replacement will require nasogastric or intravenous fluids.
Once the child is rehydrated, hydration is maintained by giving maintenance requirements plus additional fluid
to replace the fluid in every loose stool, or the child will slip back into dehydration.
Fluid requirements to maintain hydration
Table 9: Approximate fluid requirements to maintain hydration
||Maintenance requirements ml/hour
Replacing additional fluid loss in stool
In rehydrated children whose losses are not unusually profuse, advise parents to give both maintenance fluids
plus roughly 50-100 ml for each diarrhoeal stool for a child under two years and 100-200 ml for a child over two years.
As with replacement, this volume should be given in small aliquots rather than as a single large bolus.
Children who have profuse ongoing diarrhoea need to have the diarrhoea measured to calculate the additional fluid replacement
Drug therapy rarely needed for gastroenteritis in children
Even in bacterial gastroenteritis, antibiotics are not usually indicated. Antibiotics may prolong the duration
of diarrhoea and are best administered on the basis of a laboratory result.
Antibiotics are required for bacterial gastroenteritis complicated by septicaemia and for cholera, shigellosis, amoebiasis,
giardiasis and enteric fever.
Antidiarrhoeal and antiemetic drugs have risks of adverse effects
Anti-diarrhoeal agents, such as loperamide, should be avoided in children under the age of 12 years. They may
reduce the duration of diarrhoea but adverse effects such as sedation, ileus and respiratory depression can occur.
Antiemetic medications are not recommended. They may reduce vomiting but do not reduce the need for intravenous rehydration.
They may induce sedation, making oral rehydration more difficult.
Oral zinc may help
Oral zinc therapy given at onset of symptoms can reduce the duration and severity of acute diarrhoea but is usually
Lactose intolerance is usually mild and self limiting
Although lactose intolerance is common after viral gastroenteritis it is usually mild and self-limiting and does
not require treatment. If it does persist, a lactose-free formula is recommended for four to six weeks but this is not
necessary as a routine for all children with gastroenteritis.
Acute asthma in children aged 1-15 years
aged 1-15 years: are nebulisers or spacers best?
Spacers and nebulisers are equally effective
Many clinical trials have found spacers and nebulisers to be equally effective for delivering high dose bronchodilators
in acute asthma and they have comparable clinical outcomes.4
Spacers have the advantages of being:
- Less frightening, especially for children
- Not dependent on a power supply
- Easier to maintain
The cylindrical spacers that are available on Practitioners Wholesale Supply Orders are suitable. A mask is used for
young children. Depending on the individual child, they can usually manage without a mask once they are over three to
Salbutamol is given through the spacer one puff at a time, and 4 deep breaths are encouraged to take up each puff. Six
puffs should be given every 20 minutes up to the recommended dose. Depending on response, referral may be indicated.
The recommended dose for salbutamol in a spacer for acute severe asthma is:
Salbutamol MDI 100 microgram puffs
- Age <5 years - 6 puffs
- Age >5 years - up to 12 puffs
The use of Prednisolone should also be considered. 'Redipred' liquid 5 mg/ml is available, the recommended dose is 2
mg/kg once daily.
Patient information on spacer use and maintenance is available from bpacnz and can be ordered by faxing 0800
27 27 69 or visit www.bpac.org.nz